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Job Title


Clinical Documentation Specialist


Company : East Cooper Medical Center


Location : Mt. Pleasant, SC


Created : 2019-01-12


Job Type : Full Time


Job Description

Position SummaryArial;mso-no-proof:yes">Provide clinically based concurrent and retrospectivereview of inpatient medical records to evaluate the documentation and utilization of acute careservices. Includes facilitation ofappropriate physician documentation of care to accurately reflect patientseverity of illness and risk of mortality.Will play a significant role in obtaining accurate and compliantreimbursement for acute care services and in reporting quality of careoutcomes.Arial;mso-no-proof:yes">Arial;mso-no-proof:yes">Essential Duties and ResponsibilitiesCollaborates with physician,physician extender, nurse, case manager and Health Information Management coderto identify areas for improved physician documentation.Conducts initial andextended-stay concurrent reviews on all selected admissions and documentsfindings on worksheets, denoting all keyinformation utilized in the tracking process.Clarifies documentation in therecords utilizing assertive communication skills to guide physician, casemanager, or other healthcare professionals to make changes as appropriate toclarify documentation.Works collaboratively with thehealthcare team to facilitate documentation within the medical record thatsupports patient's severity of illness and risk of mortality in compliance withall guidelines and requirements.Responds to physiciansqueries.Enters working DRGs into the computerized clinicaldocumentation system.Utilizes monitoring tools,reports and data to track progress.Communicates findings withappropriate management staff and/or providers.Identifies the need forclinical documentation through report analysis.Assists in the development of physician queryresponse reports.Provides education and in-services as necessaryto physicians and staff.Qualifications:normal">QualificationsToperform this job successfully, an individual must be able to perform eachessential duty satisfactorily. Therequirements listed below are representative of the knowledge, skill, and/orability required. Reasonableaccommodations may be made to enable individuals with disabilities to performthe essential functions. normal">Education/Other Qualifications?Graduate of anaccredited school of nursing, AHIMA accredited school, international medicalschool?Must possess acurrent RN or LPN license or an RHIA, RHIT or CCS credential?Minimum of threeyears clinical or inpatient coding experience in an acute care setting,required; five years experience, strongly preferred?Familiarity withcoding concepts and coding software desired.?Knowledge of care deliverydocumentation systems and related medical record documents.?Knowledge of age-specificneeds and the elements of disease processes and related procedures.?Strong broad-based clinicalknowledge and understanding of pathology/physiology of disease processes.?Excellent written andverbal communication skills.?Excellent critical thinkingskills.?Excellent interpersonalskills to build effective partnering relationships with physicians, nursestaff, hospital management staff, andhealth information systems coding staff.?Ability to workindependently in a time-sensitive environment.?Computer literacy andfamiliarity with the operation of basic office equipment.?Assertive personalitytraits to facilitate ongoing physician communication.?Ability to stand and walkfor periods of time is required in the performance of job responsibilities.?Working knowledge ofMedicare reimbursement system and coding structures/national coding guidelines.Job:Medical RecordsPrimary Location:Mount Pleasant, South CarolinaFacility:East Cooper Medical CenterJob Type:Full-timeShift Type:DaysEmployment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.